What is Naloxone (Narcan)? Naloxone's Key Role in Suboxone Treatment And Relapse Prevention

February 4, 2021

What is naloxone (“narcan”)?

Naloxone (brand name “Narcan”) is an FDA-approved life-saving medication used to reverse an overdose from opioids: a) medications prescribed to treat pain, like methadone, codeine, morphine, oxycodone (Percocet), hydrocodone (Vicodin), fentanyl, hydrophone (Dialudid) and b) illegal drugs, like heroin and fentanyl.

Giving someone naloxone is similar to performing CPR. When you give it to a person who has overdosed on opioids, naloxone can bring them back to life and prevent them from dying of an opioid overdose. 

Studies have shown how effective it is in saving a person’s life: naloxone can increase their rate of surviving by eight-fold (1), and survival rates after administering it are between 83-100%. (2)

How does naloxone work?

Opioids bind to receptors in our brains, spinal cords, and GI tract, causing a variety of effects on our body, such as decreasing pain levels, altering our mood (causing a pleasurable, euphoric “high” feeling), slowing our breathing, and causing constipation.

When too many opioids are taken (“opioid overdose”), a person STOPS breathing. (AKA “respiratory depression.”). After only 3-5 minutes without oxygen, brain damage will start to occur, which could lead to death.

Naloxone works as an antidote, also known as an “antagonist” to the opioid receptor. When it is given to a person who has taken too many opioids, it pushes the opioids off the receptors, thus allowing that person to breathe again.

Is Naloxone safe? What happens to someone when they get naloxone? 

Since naloxone works as an antidote to an opioid overdose and quickly pushes opioids off their receptors, the person will experience immediate withdrawal--body aches, dizziness, weakness, nausea, stomach pain, diarrhea, fever, and chills. These symptoms are not pleasant, but naloxone will allow them to breathe again and SAVE THEIR LIFE. 

So, while giving naloxone to someone will make them feel uncomfortable, having these uncomfortable feelings means it IS working.

If you give it to someone who does NOT need it or if someone accidentally consumes it who does not need it (like a kid), it will have NO effect.

Naloxone is considered very safe. There is a small possibility that someone could be allergic to naloxone (they develop hives or have swelling in the face, lips, or throat). This is true for ANY medication. If a patient experiences an allergic reaction, seek medical help immediately.

The “BIG PICTURE” is that an opioid overdose IS DEADLY. It only takes a few minutes of not breathing to cause permanent brain damage. Naloxone reverses this process and allows the person to breathe again. 

Who is at risk for an opioid overdose?

People at risk for an opioid overdose include those who are:

  • prescribed high doses of opioid pain medications
  • prescribed “extended release” or “long-acting” pain medications (labeled “ER” “XR”, “XL”, “LA”)
  • deliberately misusing (taking too many) prescription opioids
  • taking opioid medications not prescribed to them
  • using illicit opioids like heroin and fentanyl
  • using opioids contaminated with more potent opioids (like fentayl)
  • given a prescription where the provider miscalculated the opioid dose
  • given too many opioids due to a pharmacist error
  • confused or misunderstands the directions for taking opioids
  • taking other medications that can slow breathing, such as benzodiazepines (like Klonipin, Xanax, Ativan, Valium), sedative hypnotics/sleep medications, and/or drinking Alcohol
  • not used to having opioids in their bodies/have a period of “abstinence” from opioids. For example, people who recently completed a detox program or were discharged from the emergency room or people who have been in jail are at high risk from overdose. It only takes 3 days of not using opioids for the body’s tolerance levels to go down so that the body is no longer used to having opioids. If that person then takes large quantities of opioids at once, they can easily overdose.

Does naloxone work for non-opioid overdoses?

NO. If someone overdoses on other medications or drugs-- like benzodiazepines (Xanax, Klonipin, Ativan, Valium), cocaine, methamphetamines-- Naloxone will not work. It only works for opioids.

Still, if you are not sure what the person overdosed on and there is a possibility that they overdosed on opioids, a good rule of thumb is to GIVE naloxone. The worst case scenario is it won’t do anything. The best case scenario is you can save someone’s life!

What are signs of an opioid overdose?

While opioids bind to opioid receptors and activate the “reward centers” creating a “high,” they also activate the respiratory center causing respiratory depression. These can look VERY similar. So, how do you tell the difference between a “high” and an overdose?

Signs of overdose:

  • less than 8 breaths per minute, shallow, or no breathing
  • gasping for air when sleeping, gurgling, or deep snoring
  • not speaking
  • pale or bluish skin; blue/gray nails and lips
  • slow heartbeat or no pulse, low BP
  • pinpoint pupils
  • Not arousable; no response to sternal rub



Practical tips: 

Tip #1: Rub someone’s chest VERY hard (sternal rub). If you are able to arouse them/wake them up at all, they have NOT overdosed.

Tip #2 Let the person know you plan to “narcan them.” People who are in a high will NOT want narcan, as it will cause them to experience withdrawal symptoms. If they resist, they have NOT overdosed.

Tip #3 Bottom line: When in doubt, give someone NARCAN! If they have not overdosed, it will put them into withdrawal, but that’s just uncomfortable. If they have taken another (non-opioid substance), narcan simply won’t work. But if they have overdosed on opioids, YOU WILL BE SAVING A LIFE!

 What are the steps to reverse an opioid overdose?

  1. Call 911!!!** 
  2. Begin Rescue breathing (1 breath every 5 seconds)
  3. Administer nasal Naloxone (if no response, repeat every 3-5 minutes)
  4. Stay with the person until help arrives

Keep in mind, if someone is not breathing, the most important thing to do is RESCUE breathing. Rescue breathing helps all types of overdoses as you wait for emergency personnel to arrive.

**When you call 911, do you have to tell the operator what drugs were used?

No, there are studies that show that reporting what drugs were used slows down response time (due to stigma associated with drug use). All you have to do is say that you see a “person is not breathing and turning pale”. Also note that the Good Samaritan law protects anyone who calls (even if the person who calls was also using drugs).

Naloxone can reverse an overdose, but can it also wear off?

Yes! Once administered, naloxone can stay in the body from 30-90 minutes. Most opioids can stay in the system much longer than naloxone. So, once naloxone wears off, the opioid (that caused the overdose) can rebind to the opioid receptors and a person can overdose again. So, they might require multiple doses of naloxone.

A person is not considered “in the clear” until waking up and being observed for at least 2-4 hours.

How soon after someone uses opioids can someone overdose?

It depends on the opioid consumed and how strong the opioid is. Overdose (respiratory depression) usually occurs 1-3 hours after a person takes the opioid. However, with stronger opioids like fentanyl (which is 50- 100 times as strong as heroin), overdose can occur within 2-5 minutes after consumption. A person can be walking around looking fine and then they can collapse suddenly.

This gives responders little time to intervene and why so many overdoses are occurring. If someone went to the bathroom 5 minutes ago and has not yet come out, they could have overdosed.

How can I get naloxone?

Your doctor can prescribe it to you.

It is also available at pharmacies without a prescription.

Most private health insurance plans, Medicare, and Medicaid cover it.

Policies may vary by state.

Who should receive naloxone?

As of July 2020, in order to reduce opioid overdoses, the U.S. Food and Drug Administration recommends that naloxone be given to:

  • people who are prescribed opioid pain medications
  • people who have a history of opioid addiction (“opioid use disorder”)
  • people who have previously had an opioid overdose
  • patients being prescribed opioids who have kids in the house or other household members who may accidentally ingest opioids

Additionally, since we are all potentially “first responders,” it is a good idea for everyone to carry naloxone on them and know how to use it.

What formulations does naloxone come in?

Naloxone is available as a nasal spray, an injection into the muscle (“IM”), or into the blood (“IV”). The nasal spray is the formulation that people commonly carry with them and is easily administered.

How should naloxone be carried/stored?

Since it is very possible you could come into contact with someone who has overdosed on opioids at any point--while walking in your neighborhood, out shopping or running errands, at restaurant, at a gas station, using public transportation, at a party, etc, it is a good idea to carry naloxone. Anyone could be a potential “first responder!”

You should keep naloxone in a place that is readily accessible and that you won’t forget!

You should keep naloxone at a temperature between 40-104 degrees Fahrenheit and replace it if it is exposed to more extreme temperatures and/or the expiration date passes.

How should I avoid opioid overdose?

  1. Take medication only if it has been prescribed to you by your doctor. Make sure to tell your doctor about all medications you are taking.
  2. Do not take more medication or take it more often than instructed.
  3. Call your doctor if your pain gets worse.
  4. Never mix pain medications with alcohol, sleeping pills, or any illicit substance.
  5. Learn the signs of overdose and how to use naloxone to keep an overdose from becoming fatal.
  6. Teach your family members and friends how to respond to an overdose.
  7. Dispose of unused medication properly.

I have heard that naloxone is also in Suboxone--the medication that treats opioid dependence and addiction. Is that true?

Yes, there are two ingredients in “Suboxone” and other brand name formulations used to treat opioid dependence.

  1. Buprenorphine: this is the “active” evidence-based ingredient that helps patients who have dependence or addiction to opioids. It has been proven to reduce cravings for opioids, prevent opioid withdrawal, and protect a person from opioid overdose. For more information on how Suboxone works, click here.
  2. Naloxone: this was put in the Suboxone formulation in order to ensure people are taking Suboxone correctly and are not misusing it. When Suboxone is taken correctly (letting it dissolve under the tongue), naloxone is NOT absorbed. It has NO effect on the body. However, if Suboxone were to be injected (taken in a way that it was not supposed to be), the naloxone would be absorbed and cause withdrawal symptoms.

More Resources on Naloxone

Bicycle Health

Bicycle Health is a telehealth company that provides buprenorphine/naloxone (“Suboxone”), an evidence-based medication, to patients who are dependent on opioid medications. Bicycle Health helps patients enter and sustain a life in recovery and works with patients so they can meet their health goals.

To learn more about the success rates and safety of Bicycle Health’s telemedicine addiction treatment in comparison to other common treatment options, call us at (844) 943-2514 or schedule an appointment here.

Header Photo by Benjamin Voros on Unsplash

About the Author

Randi Sokol, MD, MPH, MMedEd

Randi Sokol, MD, MPH, MMedEd, is an Assistant Professor at the Tufts Family Medicine Residency Program and Instructor at Harvard Medical School. She is Board Certified in both Family Medicine and Addiction Medicine. She earned her B.A. at the University of Pennsylvania, her Medical Degree and Masters in Public Health from Tulane University, completed Family Medicine Residency at UC-Davis, and earned a Masters in Medical Education through the University of Dundee.

Citations

(1) Giglio et al. Effectiveness of bystander naloxone administration and overdose education programs: a meta-analysis. Inj Epidemiol. 2015 Dec; 2(1): 10

(2) Lewis et al. Intranasal naloxone and related strategies for opioid overdose intervention by nonmedical personnel: a review. Subst Abuse Rehabil. 2017; 8: 79–95.

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